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Presentando Medi-Cal Rx

On January 1, 2022, the Department of Health Care Services (DHCS) will change the pharmacy benefit for Medi-Cal members. Their prescription medications will be covered by a new program called Medi-Cal Rx. This does not change their Medi-Cal eligibility or benefits.

If the member is eligible for both Medicare and Medi-Cal, Medicare will continue to be the primary insurance coverage.

Prescription Billing for Medi-Cal Members After Medi-Cal Rx Transition (1/1/22 and after): Members need to bring their Benefits Identification Card (BIC) from Medi-Cal to the pharmacy with their prescriptions. Alliance identification cards cannot be used for Medi-Cal Rx billing.

BIN	PCN	GROUP
022659	6334225	MediCalRx
Medi-Cal Rx Customer Service Center 1-800-977-2273

Submit Prior Authorization requests to Medi-Cal Rx by:

Fax to 800-869-4325.
Medi-Cal Rx Provider Portal.
CoverMyMeds®
Mail: Medi-Cal Rx Customer Service Center, Attn: PA Request, PO Box 730, Sacramento, CA 95741-0730.

Please note: This does not affect IHSS members. IHSS members can continue using their Alliance ID card.

Understanding Changes in Pharmacy Benefits under Medi-Cal Rx

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¿Qué cambiará?

Starting January 1, 2022, prescriptions that are filled at a pharmacy will be covered by Medi-Cal Rx instead of the Alliance. Medi-Cal Rx is a new program provided by the DHCS to provide pharmacy benefits for Medi-Cal members. DHCS is working with a new contractor called Magellan to provide Medi-Cal Rx services.

There is no change to physician-administered drug benefit and will continue to be covered by Alliance when billed as a medical claim with HCPCS code.

For Alliance Care IHSS members, there is no change to the pharmacy benefit.

Why is it changing?

Pursuant to Governor Newsom’s January 7, 2019 Executive Order N-01-2019, Medi-Cal pharmacy benefits will be transitioned to and thereafter administered through the fee-for-service delivery system for all Medi-Cal beneficiaries (generally referred to as “Medi-Cal Rx”). Medi-Cal Rx transitioning pharmacy services from Medi-Cal managed care to fee-for-service will, among other things:

Standardize the Medi-Cal pharmacy benefit statewide, under one delivery system.
Improve access to pharmacy services with a pharmacy network that includes the vast majority of the state’s pharmacies and is generally more expansive than individual Medi-Cal managed care plan pharmacy networks.
Apply statewide utilization management protocols to all outpatient drugs, as appropriate.
Strengthen California’s ability to negotiate state supplemental drug rebates with drug manufacturers as the largest Medicaid program in the country with over 13 million beneficiaries.

Can members use the same pharmacy? Is there a preferred specialty pharmacy?

Most Alliance members will be able to use the same pharmacy they do now on January 1, 2022. If their pharmacy is not contracted with Medi-Cal Rx, the member may need to choose another pharmacy. The pharmacy locator will be available in December 2020 on https://www.Medi-CalRx.dhcs.ca.gov.

Medi-Cal Rx does not have a preferred specialty pharmacy. Our current specialty pharmacy US Bioservices is contracted with Medi-Cal Rx.

What is Medi-Cal Rx secure Provider Web Portal? How can providers register?

Medi-Cal Rx secure Provider Web Portal https://www.Medi-CalRx.dhcs.ca.gov has key functions for provider and prescribers such as:

Prior Authorization Information and Submittal Instructions
Beneficiary Eligibility Look Up
Web Claims Submission, Activities, and Inquiries.

For detailed registration and training instructions, refer to Medi-Cal Rx Training under Medi-Cal Rx | Education & Outreach or visit https://medi-calrx.dhcs.ca.gov/provider/ and click Register in the upper right hand corner.

It is important that registration be completed early so the users training and functionality are complete and active for use on January 1, 2022.

Is the formulary changing?

If a medication was on Alliance formulary, but not on Medi-Cal Rx CDL, do providers need to submit a prior authorization immediately on 1/1/22?

If the member was on a medication prior to 1/1/22 through Alliance, the same medication will be “grandfathered” for 180-day transition period. This means the members can continue to receive the same medications without prior authorization through June 2022. During 180-day period, the provider needs to submit a prior authorization for members to continue on the medication or switch to an alternative that is on CDL.
If the member has never received the medication prior to 1/1/22, the provider will need to obtain a prior authorization from Medi-Cal Rx.

What is Medi-Cal Rx Reinstatement Plan?

Reinstatement Plan (the Plan) is a phased approach to restoring select claim edits and prior authorizations (PAs) by drug class while phasing out the 180-day transition policy. Please refer to https://www.Medi-CalRx.dhcs.ca.gov para obtener más información.

For claims or prior authorization related questions/assistance, you can call the Medi-Cal Rx Customer Service Center (CSC) at 1-800-977-2273, which is available 24 hours a day, 7 days a week, 365 days per year. You can also submit questions via email to Medi-Cal Rx Education & Outreach at [email protected].

To view all of Medi-Cal RX alerts and news bulletins, please visit Medi-Cal Rx Bulletins & News page (https://medi-calrx.dhcs.ca.gov/provider/pharmacy-news/).

To receive these alerts directly to your inbox, please sign up for the Medi-Cal Rx Subscription Service (https://mcrxsspages.dhcs.ca.gov/Medi-CalRxDHCScagov-Subscription-Sign-Up).

How can providers submit prior authorization requests? How can they check status on prior authorization requests?

For drugs billed as pharmacy claims (prescriptions that members pick up from pharmacy), providers can submit prior authorization requests through Medi-Cal Rx Provider Portal, fax, or mail. Providers can check on the status of requests on Medi-Cal Rx Provider Portal or by phone to Medi-Cal Rx Call Center Line 1-800-977-2273. Please refer to https://www.Medi-CalRx.dhcs.ca.gov.

Submit Prior Authorization requests to Medi-Cal Rx by:

Fax to 1-800-869-4325
Medi-Cal Rx provider portal www.Medi-CalRx.dhcs.ca.gov
CoverMyMeds®
Mail to Medi-Cal Rx Customer Service Center, Attn: PA Request, PO Box 730, Sacramento, CA 95741-0730.

For physician-administered drugs billed as medical claims (drugs billed to Alliance as HCPCS code), providers can continue to submit requests through Alliance Provider Portal or by fax at (831)430-5851. There is no change to physician-administered drug benefit and will continue to be reviewed and covered by Alliance.

Will prior authorizations be carried over into the Medi-Cal Rx system or will new authorizations be required?

Authorizations will be carried over or “grandfathered” for their originally approved dates of services up to 1 year, unless the drug is included in the list of exceptions allowing for extended/multi-year PAs up to 5 years for certain drug classes/categories (liste below). New prior authorizations will be required from Magellan after the original prior authorization expires.

Drug classes/classifications include:
Diabetes (insulin and anti-diabetic drugs), Asthma/COPD (long and short acting bronchodilators, inhaled corticosteroids and combination products, antihistamines, epinephrine), Antidepressants, Anticonvulsants, Anti-Parkinson’s, Immunosuppressants (for prevention of transplant rejection and treatment of autoimmune disorders), Cardiovascular drugs (including antihypertensives, antiarrhythmics, alpha and beta blockers, inotropics, diuretics), Agents for chronic treatment of Rheumatoid Arthritis, Pulmonary Hypertension, Multiple Sclerosis, Attention Deficit Hyperactivity Disorder (ADHD), Alzheimer’s Disease, Gout, Antihyperlipidemics, Contraceptives, Glaucoma Agents, Hormone replacement, Thyroid disorders, drugs for overactive bladder, nasal steroids, treatment for allergies and cough.

Who do I contact if I still have questions about Medi-Cal Rx?

Who can providers contact for member-specific concerns?

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